Provider Demographics
NPI:1538407978
Name:CLARK, RONNI (MED, BCBA)
Entity type:Individual
Prefix:MS
First Name:RONNI
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1819 E SAINT VRAIN ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-4644
Mailing Address - Country:US
Mailing Address - Phone:714-501-7479
Mailing Address - Fax:877-298-4943
Practice Address - Street 1:1819 E SAINT VRAIN ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-4644
Practice Address - Country:US
Practice Address - Phone:714-501-7479
Practice Address - Fax:877-298-4943
Is Sole Proprietor?:No
Enumeration Date:2013-01-18
Last Update Date:2018-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1-15-20850103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst